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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ~� <br /> T1�57APPLICATION <br /> (For Nan-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> .),Business Name (DBA) "Address <br /> aOwner— T.-1 -.—��C� �-�_ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, Emergency Telephone No. <br /> a Contractor Licence No. 957 4927 <br /> _1-3 3 6_7 Q w <br /> Applicants Name (Print) Title. n=- , pate <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, = - June 30, 19 Disposal Sites - <br /> Description(Make/Yr.,Color) G7 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address' ' <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. !Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time eC1. <br /> 4. ❑ SANITATION PERMI ! / <br /> Job Address/Location <br /> Owner Address <br /> SEPTI ANK CESS OL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site M. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑•LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 1:1 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re u ions of th n Joaquin Local Health District: <br /> APPLICANT'S SIGNATURE X ? <br /> e <br /> 1 <br /> e FOR DEPARTMENT US ONLY <br /> Fee IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE BILLING REMITTANCE $ REMIT l <br /> EXPLANATION AMOUNT DUE CHECKED <br /> O DATE DATE REMITTED ® AMOUNT <br /> FEE .G <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ► �/ <br /> OTHER <br /> OTHER ✓ <br /> Received by Date Receipt No. Permit No. I nuance Date Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />